Episode 3Common causes of pain in the ball of the foot, why isn’t it metatarsalgia!.
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Nick Knight:
Hello, everyone. Welcome to episode three of the NK Active podcast. I really hope everyone enjoyed the last episode, chatting to Natalie and Chris about their injuries and the journey that they went on. So obviously, as everyone knows, in this podcast we are going to be chatting about pain in the ball of the foot, which is commonly, sometimes people may have heard of it, called metatarsalgia. So we are obviously joined this month by Charlie again.
Charlotte Dando:
Hello.
Nick Knight:
And then Natalie. And so, pain in the ball of the foot. Just to get a brief overview as it were, it gets called metatarsalgia, or people will say, “I’ve been diagnosed with metatarsalgia.” So just to try and set the record straight as it were, the metatarsalgia is not really a diagnosis, it is just a descriptive term for pain in the ball of the foot. And as you will see throughout this podcast, there are different reasons, and today we will just cover some of the most common reasons that we see in clinic, as to why you can get that pain in the ball of your foot. And we will then try to give you some self-help and tips, and some advice on what you can do. So Charlie, let’s first chat about Morton’s neuroma, and I come to you because you may have done a small bit of work called a PhD that…
Charlotte Dando:
Yeah, so I’ve been studying the condition for about seven years now. And what we think Morton’s neuroma is, is a development of nerve tissue. So it’s a thickening of that nerve tissue in between the toes, and classically patients often report pain such as a numbness, tingling, or burning sensation. The reason why it happens is…, we are not really sure, but what it does tend to do is to stop people from doing their activities. And it is that internal worry of knowing what it is and how to manage it. And so I guess our job as podiatrists is to diagnose and guide patients through that thinking and process.
Nick Knight:
So if we were trying to describe the main symptoms that, when someone fills in our pre-assessment questionnaire or they phone up and say… What sort of symptoms are you expecting people to say they have when they come in with that neuroma?
Charlotte Dando:
They usually feel like something is in between their toes, sometimes a tingling sensation that might be in the ball of their foot or radiating kind of up into the toes. People often find there is some numbness and it is sometimes triggered by doing sport or activity, such as running where we are kind of overloading the forefoot area.
Nick Knight:
Yep, and then with regards to treatments, how would we want to try and manage it?
Charlotte Dando:
So you kind of have conservative, which is kind of changing footwear, so having a wider, deeper fitting shoe that kind of accommodates the toes and makes sure that they are not kind of compressing them in any way that could trigger that nerve-type pain. The second option would be using something like an orthotic, and so using the orthotic to help with foot function, but then to offload that structure, so we use something called a met dome that sits underneath the toes that just kind of provides a little bit more space, a little bit more room for the person to move in their soft tissues – kind of move a little bit more freely rather than being restricted. We then have, well it goes a bit more I guess, kind of surgical, in terms of then going towards a steroid injection. So that is then placing a steroid into the tissues, and the idea being is that we reduce some of that inflammatory response and that you are starting to shrink the surrounding tissues. So again, you are creating a bit more room so the tissues are able to move freely.
Charlotte Dando:
And then the third option is then surgery, so that is then removing that additional thickened tissue. Again, by removing it, the idea is then that the foot is able to move and function a bit better.
Nick Knight:
But then the issue is that if you remove that section and nerve, you are then sort of left with a numb bit in between your toes, aren’t you?
Charlotte Dando:
Yes, you can get something called a stump neuroma, which is just a really clever way where the body goes, “Ooh, a bit of nerve tissue has gone. What I’m going to do is respond by presenting something called a nerve growth factor.” Which then starts the nerves to kind of regenerate, really, and they start to regenerate in that area. And we know that within 20% of the population who have a neuroma, you are at risk of redeveloping this when you have surgery. And you can have exactly the same experiences you did the first time round, or sometimes they can be more severe. So it’s something to consider if you’re going forward for surgery.
Nick Knight:
And that’s the one thing that I like about neuromas, because I believe that treatment pathway is quite clear cut from our perspective, it is – make sure the footwear is suitable and fits correctly, try an orthosis, or just a metatarsal dome. And if that doesn’t work then injections and then possible surgery. So there is quite a nice definitive plan and pathway in place. So there is one thing I think we can offer people here – people may share the links in the comments etc, but we have actually put together a little video on how to actually put a metatarsal dome in the right place and we have made a little box that people can get hold of from our website about what a Morton’s neuroma is effectively, because I think that metatarsal dome placement is quite key. If it’s too far back, then it’s not going to do what we want it to.
Charlotte Dando:
Yeah, and I think it’s having that reassurance, isn’t it? Making sure that you know what you think you’ve got, that you’ve got ways to manage it and that you know what your options are moving forward.
Nick Knight:
So then if we have a chat about footwear, what types of footwear do we tend to see that aggravates someone who has a neuroma?
Charlotte Dando:
So something with a heel tends to, because they are going to be overloading the forefoot, something like a court shoe where it is quite narrow in the toe area, that kind of brings and kind of compresses the forefoot. So it’s all really the pretty shoes that girls and women and men love to wear. So yeah.
Nick Knight:
That unfortunately aggravates it.
Charlotte Dando:
Yeah, sometimes some of the brogue styles as well, so the ones that come into kind of more of a pointed tapered edge can sometimes…..
Charlotte Dando:
Yeah, can recreate those symptoms.
Nick Knight:
But we’re not saying you can never ever wear those, it’s just, if you have got neuroma-type symptoms, there’s a risk that you’re going to aggravate it.
Charlotte Dando:
Yeah, and I think it’s knowing that you are going to use the footwear for the right activity, so there will be certain activities if you know that you’re spending a significant period of time on your feet, that you are wearing the right footwear to live and work with it.
Nick Knight:
Yeah, I think that’s pretty sensible. So now let’s move on to almost a sort of, well by mistake, it’s become a sort of quite a pet topic of mine, hasn’t it – plantar plate injuries – and Natalie in a minute can chat about the rehab behind it, because she is most probably one of the only sports therapists out there that can feel quite confident in rehabbing a plantar plate injury, because personally in clinic, it is the most common condition that I actually see. And as you well know from episode two, that’s where obviously Chris came on, and that is the injury he had, was that plantar plate injury. And it is something that I think is massively overlooked and is actually most probably the most common cause of pain underneath the second toe. So the second toe is the most commonly affected joint. With Chris I think it was under his third or fourth, so not as –
Natalie Green:
Third, yeah.
Nick Knight:
Third. So not as common, but it’s still theoretically possible. And the plantar plate is essentially a small structure that basically attaches your metatarsal, so that long toe bone – for everyone that is old enough to remember the ‘Beckham Boot’, that is the bone that David Beckham fractured and then went into the Aircast boot and then basically then it attaches to the toe, and effectively anything that means trying to prevent the toes from sort of bending upwards, any sort of bending upwards motions of the toes is what is then going to aggravate that plantar plate. And you will typically come in presenting with a feeling like you are walking on a pebble or you’re getting this constant ache, and then when you don’t think about it, symptoms will be worse on long periods of standing or when you’re walking up the stairs or you’re pushing off. So you’re really starting to bend those toes upwards. And luckily for us in clinic, we know that actually you can reliably diagnose these without having to refer for lots of imaging, which is actually quite helpful.
Nick Knight:
And the other way that you will notice this is that you often quite find in the chronic injuries, there won’t be a sudden onset, that it will be building up over time. But you can get acute ruptures of the plantar plate, but they always come after a period of jumping around. So being on the south coast here, the majority of times we see a plantar plate rupture is people jumping off boats onto a jetty or something like that in their sort of boat shoes, as it were, that then come back and say, “I’ve done that. I felt a pop. My foot swelled up underneath my second toe.” And you think, “Okay, this is a plantar plate rupture.” But without just the conservative overload issues then, from a rehab perspective, Natalie, what are we looking at trying to do or to achieve, to try and help make these slightly better?
Natalie Green:
So, yeah, the rehabilitations – typically we start to focus on strengthening the ankle and also the toes as well. So we concentrate on the lesser toes, so the second and third toes especially, wrapping the TheraBands around. So in clinic we use different colours of TheraBands, which is the different resistances, so usually we start a patient on a yellow, which is the easiest resistance. And then for them to see their own progression, for us to see strength gaining in that limb, we take them all the way through to the black band, which is the hardest, and then we know that we have gained sort of maximal strength in that area.
Nick Knight:
And then once we have obviously built up the strength in the toe doing the toe flexion and working on the foot intrinsics, then what do we then do to look at moving people along to doing afterwards?
Natalie Green:
So we go more proximal, so we concentrate on the hip strength, core strength, thigh, hamstring strength. And then we sort of go from there, really.
Nick Knight:
And I think the other thing that we will then look at doing is getting people to actually go up on their tip toes and do calf raises. There are some people out there who think that actually, if you’ve got a plantar plate injury, you can’t go on and do calf raises, because that’s going to aggravate the problem. But our philosophy here is , well, if you’re a runner or you like rambling, or walking for example, well, in every step you take you effectively then do that, going up on your tiptoes. So we need to get you back, ready to do that activity.
Natalie Green:
Definitely, I think that was one thing that Chris, in the episode previously, he struggled with calf raises and we started doing seated calf raises, so he would literally have legs at 90 degrees, raising the heels off the floor, adding weights, and then getting to standing raises as long as it was all pain-free. And that has been the most beneficial throughout the patients that I’ve seen, especially. And it’s given them the confidence to feel that they have that strength in the toes and it’s not going to cause any pain.
Nick Knight:
And then Charlie, from an orthosis perspective or an insole perspective, what can we look at doing to try and sort of help out with these?
Charlotte Dando:
So with these guys, you don’t really want to be blocking the movement because you’re going to start to irritate. So we’ll use something like a U-shaped cut out that we’d want to make sure allows the metatarsal to drop down into that space when the foot is going through its movements. We may even start to think about something like a metatarsal bar or a dome to be able to just then support the forefoot structure.
Nick Knight:
And then what is the important thing with regards to that sort of ‘U’ cut out? What are the mistakes that some people make with that?
Charlotte Dando:
Most people tend to put it too far proximally, so it’s making sure that it’s situated in the right place which is just before where the metatarsal head sits, so it gives that complete free range of motion.
Nick Knight:
Yeah, so we are aiming just with the toe, just to be able to drop down, because the issue is, if you put that cut out too far back, you actually then encourage the toes to bend upwards, which then in turn could aggravate the problem, not make it better. The other thing that you can also try that can be really helpful, is actually taping the toes as well. I sort of call it the ‘breast cancer ribbon sign’ as it were. So you are taping that toe down just to try and offload it and try and reduce the symptoms. And that can be really helpful, a sort of get out of jail trick.
Charlotte Dando:
Yeah, I would say definitely for the first couple of weeks. It just allows everything to calm down, break that cycle of inflammation and then just allows, I guess, Natalie, to work on the rehab beautifully.
Natalie Green:
Yeah, and I think that’s what I have found as well. We have put the tape on and it has already given them sort of a sense of relief and then they’re confident do the exercises. And then, like you say, a few weeks down the line, we take the tape off because we say it’s not a long-term fix, it’s short term while we get the strength there and then the strength takes over that tape.
Nick Knight:
And footwear wise, what’s my particular favourite shoe?
Natalie Green:
The Carbon X of the Hoka’s, so that’s Chris’s favourite shoe and I have never seen him so happy to be honest, as soon as he put the shoe on, he was walking around and was like, “The pain’s sort of gone.” And we’ve prescribed a few patients with them and they’ve absolutely loved them. Yeah, really, really good shoe.
Nick Knight:
And the reason behind that, so the Hoka Carbon X is a carbon plated shoe with a rocker. So that means if you look at it from the side on, the front of the shoe sort of lips up, as it were, and it is completely rigid. So as you then go to push off, the toes can’t bend up. So you then reduce the risk of aggravating or flaring up that plantar plate as it were, and this is why people find that shoe really helpful. Before the Hoka or Carbon X came out, we used to give people carbon linings, but now that the Hoka Carbon X has come, we haven’t had to use that as much. And the interesting thing about managing these conservatively is that when you actually look at the literature from our viewpoint, there isn’t actually any sort of guidance out there.
Nick Knight:
There are a couple of papers and that’s it, but everyone talks about operating on these. So what we are hoping to do here at NK Active, is, we have got a nice case series of people that have gone through the journey back to activity, so we can then possibly start trying to add to the literature so we can start to say, “Look, this is what we do. These are the results that we’re getting with it. So then that means that it can then help to educate other colleagues, to then try and help people who can’t get to us, manage these slightly better.” So let’s now move on to the subject of bunions. Charlie, what is a bunion?
Charlotte Dando:
So a bunion is where the big toe joint has decided to deviate or move and it usually deviates into the lesser toes, and then it creates this kind of bump or lump on the side of the foot that usually ends with kind of reduced mobility, pain discomfort. So, yeah.
Nick Knight:
And is there any things that could be done that could aggravate or increase the risk of that bunion developing?
Charlotte Dando:
So there is evidence to suggest that if you have an inflammatory condition, so something like your arthritis, that you’re more at risk of having bunions, hereditary, so looking at family can also give you an indication. Footwear has been applying those additional forefoot loads, so a higher heeled shoe can put your forefoot at risk of those structures becoming exacerbated and then soft tissue and bone changes consequently. And then I guess just natural injury. If you are to trip, slip, fall and do something with the big toe, then you’ve changed that structure integrity and then over time it changes.
Nick Knight:
So then one of the things we get asked about a lot are splints.
Charlotte Dando:
Ah, the toe splints.
Nick Knight:
The toe splints. What are your views on toe splints?
Charlotte Dando:
So the forces that go through the big toe are huge, and sadly splints aren’t strong enough to cope with that demand. So actually they’re probably not doing very much, although there is this idea that they may have what we call a placebo effect. So for 40% of people who use them, they’ll see that there’s an internal benefit and that’s just a perception. And if that works for people, then that’s great, but I guess the scientist part of my brain goes, “They’re not changing any tissues. It’s not changing the structure of the foot in any way. It’s just maybe offering short term relief.”
Nick Knight:
Yeah, no, I can 100% agree. And then the other thing is, do you think there’s a role for foot orthoses with regards to bunions or not?
Charlotte Dando:
Yeah, it depends on the severity. So if you have a fairly functional, mobile foot, then I think the use of orthoses can be of benefit to helping that foot load a little bit better. I think if we’re at the more latter stages of having bunions where the deformity is more rigid, then I think it’s more going down that kind of conservative look of how to make you comfortable and how to manage your pain.
Nick Knight:
But we’re not looking at orthoses to try and say, “We want to give someone some insoles to slow the progression down or reduce the risk of getting one in the first place.”
Charlotte Dando:
No, the progression will just happen, it’s more about managing pain. We won’t change the foot shape, so the foot shape is the foot shape. So I think that’s also to bear in mind, just the orthoses won’t naturally change the shape of your foot. It can just mean doing the activities or things that you love can become a bit more do-able, achievable, or easier.
Nick Knight:
Yeah, and then with regards to exercises. Okay, we know there’s limited evidence out there suggesting that by doing exercises we will slow the rate of progression or stop, but in general, what exercises could people be doing around their toe, just to try and make it as strong as possible?
Natalie Green:
Yeah, so big toe flexion extension, the lesser toes flexion extension. We can do ankle inversion, ankle eversion, plantar flexion, dorsiflexion. So that sort of up/down movement of the foot, and then going sort of more proximal to calf raises, and then also balance work as well. So starting on the floor, then adding a towel underneath, closing your eyes, wobble cushion, and making it harder each time. And then again, working proximally to that sort of hip/core.
Nick Knight:
Yeah, no, and I think that is really important, because okay, we’re not looking to change a deformity doing that, but it may be quite helpful in managing those symptoms and pain and whatnot. So another common one that we then see in clinic is intermetatarsal bursitis. So did you want to have a chat about that Charlie, and what that is?
Charlotte Dando:
Yes, this is like a fluid filled sack that sits in between the toes. I always think of it like a car, they are like the shock absorbers, so as we are loading and offloading the foot, these guys just sit there and stabilize the other tissues around it. If for whatever reason a joint is being overused, these guys will inflate to try and add a bit more kind of shock absorption, and that’s when we get the permanency of them being inflamed, this is what we call a bursitis.
Nick Knight:
And then do we think it’s possible that you could have more than one condition coexisting at once?
Charlotte Dando:
Most definitely. So I don’t know whether it’s just the nature of our clinic, where we naturally get people with more pathologies that kind of coexist, but through the research that I’m doing at the university, it’s becoming more likely that pathologies do just co-exist. They’re all anatomical structures that are there within your foot, and it makes sense that if you’re aggravating one structure, that you’re probably going to aggravate others in that process. So a lot of what the rehabilitation does, is being able to let those structures learn to rework together again, and that those that may have switched off or aren’t working correctly can gain that control and strength. And then those that maybe have been working too hard are then able to then do the jobs that they were initially designed to do.
Nick Knight:
And then Natalie, from an exercise perspective, okay, we can’t do an exercise to reduce the size of that intermetatarsal bursitis, but again, would you sort of agree that the exercises you would then look at doing for that compared with trying to strengthen up the foot in general – is there anything else that you would add in or would you say actually no, just by doing those simple toe flexion exercises and then sort of working on the foot intrinsics, that should be perfectly adequate?
Natalie Green:
I think so, yes, especially the foot intrinsics, so sort of bringing your toes up as if you’re going to curl them up and then not curling them up completely, because that works those top of the foot muscles underneath as well. And yeah, I think I’ve seen a lot of patients with bursitis, and they’ve all benefited from the same sort of procedure of the ankle strength, foot strength, and yeah, it sort of progressed that way.
Nick Knight:
Well, it just fits into the whole remit here at NK Active of just getting people fitter and stronger.
Natalie Green:
Definitely, and I think as well, sort of the older population, we start them off with ankle exercises to help their pain, and then by the end of it, they’re squatting, they’re doing lunges and they can actually do a lot more functional stuff outside of the clinic. So they are going on more walks and they’re enjoying it and they’re picking up different sports because of it. So it sort of gives people a new lease of life as well, able to work those different limbs.
Nick Knight:
And I think with that, there is also lots of evidence supported that by working on the things that, especially in the older population, are reducing the risk of people falling over as well. Because I think we could in this country have a big issue later on with an increased risk of falls with the older generation.
Natalie Green:
Definitely, yeah.
Nick Knight:
So then if we then… Sorry, Charlie you were about to say something?
Charlotte Dando:
I was just saying, I think it just shows you how complicated the forefoot is and that’s probably why the umbrella term metatarsalgia came about, because actually there’s lots of things going on. There’s lots of interventions. I guess here it’s that we’re trying to document which ones we should implement and then at what stage, and so yeah, for your bursitis, neuroma and your bunions, it is a combination of rehabilitation, orthoses, footwear and self care.
Nick Knight:
And then that’s what we think, and then obviously you can go into the realms of injections and surgery, but then that’s when we look at referring onwards, especially for that surgery part. But as you say, it is a complex area. That’s just four conditions we briefly brushed over, but there are loads, plenty more things that can cause pain in the ball of your foot. And you think the ball of your foot is a quite a small thing relative to the size of your whole body. And you sort of think, it’s a complex structure. But we’re biased, we’re going to say that because we deal with foot problems day in, day out. So then thinking about the conditions, going back to that neuroma, if there was sort of three tips that you could give someone to try and say what to do if they think they’ve got one or how to try and self manage it, what would they be?
Charlotte Dando:
I think it would be first of all looking at the type of footwear that you’ve got. So not saying that you don’t have to wear the shoes that maybe aggravate it, but look at how often you’re wearing them and how long for. So sometimes it can just be that you’re wearing them three consecutive days in a row and that’s where it’s becoming uncomfortable. So maybe only just wearing them for two days, it makes life a bit more easier. Probably secondly, looking at the type of shoes that you are wearing. So I always think a really lovely thing to do is to draw around the sole of the shoe and then draw around your own foot on top of it. And does your foot actually fit into that shoe? It’s amazing how many people squeeze their feet into shoes.
Nick Knight:
And I love that, because it’s amazing how many people think their shoes fit. However, then when they do that and they think, it’s almost just like a light bulb moment because they see it and they sort of realise ‘my foot is spilling over the side of this template’. Obviously then the shoe is going to compress, and then obviously aggravate this neuroma. It’s then almost like the penny drops as it were. So then was that two or three? I can’t remember.
Charlotte Dando:
That’s two, and I guess the third one is probably trying the met dome, so placing that in a pair of shoes – you don’t need anything over complicated. It is a little dome foam shape that you can slot into shoes. And I think that’s a really good way to know whether you would be amenable to maybe having an orthotic longer term to help ease those symptoms.
Nick Knight:
So if I was then thinking plantar plate, if I was thinking about three things, for me it is really focusing on those symptoms of the ache. It may swell slightly, feels like walking on a pebble and it hurts as you push off. That’s for me, quite the tell tale signs. And then if you think you have got one, it’s then working on starting to build up that strength within the toes. And then it’s, again, that a metatarsal dome can be helpful just to try and offload that area, along with some taping at the same time. Bunions, three tips for those. So managing those.
Charlotte Dando:
Probably a shoe with a bit of a rocker. So similar to those with plantar plate, having something that allows you to propel a little bit more forward. So then a rocker in kind of a walking-style shoe is usually quite good if that’s where you want to get the activity and the duration of activity to continue.
Nick Knight:
And then there’s a, forgive me as I’m not going to pronounce it right, it’s Hanwag.
Charlotte Dando:
That’s it.
Nick Knight:
It’s a boot, a boot that they call their bunion walking boot, and it’s basically a boot that is seamless all around. It’s like a bit of, I think it’s neoprene-type material, that is sort of soft around that bunion region, so nothing then rubs.
Charlotte Dando:
I guess it’s finding footwear where the material conforms slightly to your foot shape. I think that’s really helpful so that you’re not then not doing activity, because I think that’s a frustration and what a lot of our patients say is that they’re having to stop the activity because they can’t find footwear. So yeah, finding footwear that works for you.
Nick Knight:
Yep, and final tip for bunions?
Charlotte Dando:
Oh, I think it’s about well to go fact finding about what the long-term effect of maybe going down the surgical route is, so making sure that you’re really well-informed to be able to go and make those decisions and that it’s to OK to go down that surgery route, it’s not necessarily a bad thing. It’s just making sure that in your head you’ve ticked all the right boxes for you to feel confident to do that.
Nick Knight:
No, well definitely, because surgery is a perfectly plausible treatment plan for bunions, because that’s the only true way you are actually going to physically resolve it. Anything we do conservative, isn’t going to resolve it. It’s a bony shift, it’s a bony change, a bony deformity. So we’re not going to change the physical appearance of that conservatively at all. So going down that surgical route with your orthopedic or podiatric surgeon is still a perfectly viable treatment option, isn’t it?
Charlotte Dando:
Yes.
Nick Knight:
And then finally, we won’t do three top things with bursitis, because they’re going to be very similar to what you would say for neuroma, but then sort of bringing things to an end, your three sort of top foot exercises, as they are, for people.
Natalie Green:
Probably ankle inversion, eversion. So the amount of people where I actually do the ankle inversion, eversion with them and they’re like, “I didn’t realise I used these muscles.” So that’s probably one of my most popular ones, just because it gives more people sort of a more stable feeling in the ankle and especially when we can actually show them the progress with the different colour bands. The second one would probably be the lesser toe flexions. Again, that’s a great one to work the top of the foot muscles going into the flexion extension. And probably my third one is probably calf raises. I think it’s such a fundamental movement that everyone actually does in a day-to-day activity, and it’s definitely one to sort of have in your top three exercises.
Nick Knight:
Perfect, so I think we can… one second, make sure I’ve covered all of my notes. I have a memory span of a goldfish, so let’s have a look. Yeah, no, that is all my notes covered, ticked off. So I think we can then look at bringing it to an end. So once again, thank you, Natalie. Thank you, Charlie, for coming on. Hopefully that was really useful for people. Next month unfortunately, Natalie and Charlie will not be on the next episode. We’re going to have Caroline French from French and Sons and Dawn Taylor from Alexandra Sports coming down, chatting all things sort of running/athletic footwear and day to day. And anyone sort of in the Southampton area, you would have heard of Alexandra Sports and I got my first ever running shoes from there, and French and Sons is almost like a local historic place within Southampton.
Nick Knight:
That’s where my children got their first shoes from as well. And when you speak to patients, you sort of say, “My daughter got her first shoes from there, I got my first shoes in there, and then my gran actually took me to get my…” And you can hear there’s that long heritage, so we can chat all things footwear about what’s coming up and latest technologies and everything, and different shoes to help with different conditions. So don’t forget to obviously subscribe to the podcast, we are on all your standard sort of podcast channels. And don’t forget to like, and sort of share the video and subscribe to our YouTube channel as well. Really hope you enjoyed the episode. If you’ve got any questions, comments, feedback, or anything you want us to chat about in future episodes, please do let us know. Otherwise we shall see you on episode four, take care.